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C19161.0''Ot]22. <br /> L <br /> eee= Waste Tire Survey & Inspection Report Inspection Report Number <br /> I1 - 1088473 <br /> State of California <br /> CIWMB 181(teManag) Survey Form - Page 1 _ <br /> California Integrated Waste Management Board — <br /> Part A- urvey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- ` i ! �- 1-71 <br /> i Inspection Type (Fill one) <br /> Site Suffix: 1 i O ! Q P Q Q <br /> Routine Re-inspection Referral Observation <br /> Local ' , If Referral,choose referral type(Fill one) <br /> Identifier: L —(�� Ofi!i�t(� (V Q CHP Q CIWMB Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name v <br /> Inspected By Inspector <br /> Physical dress C� 3 l - I V ' ' & <br /> x.05 E. mn .S <br /> Street <br /> Inspection Date <br /> S'r.J %Coty TimeIn Time <br /> O,uvt <br /> i . <br /> Business Rep Tit ej ;O AM I r 1 O AM <br /> PM <br /> R0141 Ze/ <br /> - - - - - - Operational Status Tire Type Business Role Storage Type <br /> Tire Count(Whole/PTE) <br /> (Fill one only) (Fill all that apply) (Fill all.that apply) (Fill all that apply) <br /> � .S b <br /> ' t O Active ® Passenger Is Generator Q Outdoor <br /> Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> -. O Q Inactive �Truck <br /> Longitude - Q End-Use ®Container <br /> Q Planned Q OTR <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet (S Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other I — <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Q Q Notice Of Violation Q Extension <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. C-ompliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q O 14 CCR§18459 -Responsible Entities Complying With Manifesting Requirements Date <br /> Q Q 14 CCR§18459.1 -Tire Program 10 Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or FXT) <br /> O O - ---- — <br /> 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators ® In Compliance - No violations <br /> Q 1 Q Other: <br /> Comments <br /> ��,: 1. -Ft�c�`� _ c,Co �►_rte o_�s_ �►_�c u es —w4.��-J -�--eL, <br /> Inspection Form Included: Q !/ �D - ((��ahone <br /> Comments Included: Q — �B sines Rep' t a Phone Number nspec 's Signature Number <br /> INSTRUCTIONS ON BACK •� rrect: Incorrect: Xhh A P L .11,12 3 62081 <br /> White op .CIWM Yellow Copy Operator Pink Copy.LEA <br />